Medicare and Medicaid

In a recent Advisory Opinion (No. 26-01), the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) concluded that waiving cost sharing for certain commercially insured patients who receive a cancer screening test is permissible under the federal Anti-Kickback Statute.

The opinion pertains to a clinical laboratory test that screens for…

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services recently issued an unfavorable Advisory Opinion (No. 25‑12) addressing a home health care agency’s proposal to offer sign‑on bonuses to prospective employees who are in a position to refer patients (usually family members) to the employer for home care. The…

In an unfavorable Advisory Opinion issued last week[1], the Office of Inspector General, U.S. Department of Health and Human Services (OIG) found that a home care agency’s plan to market sign-on bonuses to prospective employees with the intention of employing those individuals to provide services to family members could result in sanctions for…

The 21st Century Cures Act (Cures Act) required states to adopt electronic visit verification (EVV) systems for Medicaid-covered personal care services (PCS) by January 1, 2020 and for home health care services (HHCS) by January 1, 2023. According to the Centers for Medicare and Medicaid Services (CMS), the EVV requirement was imposed “in response to…

The U.S. Department of Justice recently announced a settlement with Patients Choice Laboratories (“PCL”), a diagnostic laboratory headquartered in Indianapolis, Indiana, under which PCL will pay over $9.6 million to resolve allegations that it violated the federal False Claims Act (FCA) and Anti-Kickback Statute (AKS). The government alleged that the lab knowingly submitted claims to…

The 2025 National Health Care Fraud Takedown, announced in June, was the largest in history, with 325 defendants charged (including 96 providers) in 50 federal districts. In all, the charged schemes involved more than $14 billion in intended loss, and more than $245 million in cash, luxury vehicles, cryptocurrency and other assets were seized. These…

In October, two medical transportation companies were charged with or indicted for fraud in New York.   

The owner of Pearl Transit Corp. (“Pearl”), Jael Watts, was accused of running a sham transportation service that supposedly provided rides for persons with disabilities and seniors in Westchester, Putnam, Rockland, and Suffolk counties. In 2024, the…

The New York Attorney General’s Office imposition of a $250,000 penalty on MVP Health Care for maintaining an inaccurate mental health provider directory riddled with “ghost” providers was recently discussed here. The problem, however, extends beyond New York. The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently issued a…

Sligo Creek Center, a Maryland nursing home, recently appealed the constitutionality of the Centers for Medicare & Medicaid (CMS) enforcing a $1.5 million fine without a jury trial. The fine related to the facility’s failure to establish and maintain an infection control program. The appeal, currently pending in the Fourth Circuit of the…

The New York Office of the Medicaid Inspector General (OMIG) publishes audit protocols to “assist the Medicaid provider community in developing programs to evaluate compliance with Medicaid requirements under federal and state statutory and regulatory law.”1 Such protocols are “applied to a specific provider type or category of service in the course of an…